Vol 19, No 3 (2015)

Background and objective: Hyperlipidemia refers to elevated levels of lipids and cholesterol in the blood, and is also identified as dyslipidemia, to describe the manifestations of different disorders of lipoprotein metabolism. The aim of this study was to investigate the available and commonly distracted natural and synthetic antihyperlipidemic agents in herbal shops, pharmacies and prescribed by physicians in Erbil city, and to determine physicians' response for the use of natural products. 

Methods: Between November 2013 to February 2014; 20 herbal shops and 40 pharmacies in Erbil city were visited randomly for asking on available and most commonly distracted natural and synthetic antihyperlipidemic agents. Forty doctors at private clinics were asked about the most frequently prescribed natural and synthetic antihyperlipidemic agents in Erbil city.  

Results: Of eight synthetic drugs available in pharmacies, statins were considered the first line agents as antihyperlipidemic drugs particularly atorvastatin and rosuvastatin. Of 16 natural products available in Erbil herbal shops and pharmacies, garlic and omega 3 give positive response by patients and highly distracted by pharmacist and herbalist. Of 40 physicians, 27 (68%) prescribe both natural and synthetic agents while only 13 (32%) prescribe synthetic drugs as antihyperlipidemic agents for patients. 

Conclusion: Statins used in first order as antihyperlipidemic drugs and uses of natural products, as lipid lowering agents in Erbil, is getting larger interest by people, herbalists, pharmacists and doctors. Of 40 doctors, 68% prescribe natural products along with synthetic drugs but also there is a need to educate the people on how to use these natural agents and choice suitable products for them.    

Background and objective: Pertussis is one of the vaccine preventable diseases. Bordetella pertussis (B. Pertussis) continues to circulate even in countries with good childhood vaccination. The aim of this study was to evaluate patients suspected or confirmed to have pertussis in relation to certain clinical and laboratory data.      

Methods: A prospective study was conducted in Rapareen Teaching Hospital from June 1^st, to September 1^st, 2010. The study enrolled 651 inpatients below five years of age with respiratory tract infection with 72 of them having initial suspicion of pertussis. Demographic and clinical data were obtained from them and nasopharyngeal swab were sent for culture for isolation of microorganisms as well as blood samples obtained for haematological assessment (white blood cell differential count and platelet count). Those confirmed to have pertussis and para-pertussis were considered as group A while other culture results were considered group B.  

Results: Most of patients were below one year of age (56.9%) with large numbers  were not properly vaccinated and they had positive family history of paroxysmal cough (68.1% and 58.3%, respectively). Twenty one patients confirmed to have pertussis and parapertussis by culture methods. There was no significant difference between patients with group A when compared to group B regarding gender, vaccination status, history of post-tussive vomiting or whoop and family history of chronic cough. Mean platelet count was significantly different between two groups, with pertussis and parap-pertussis cases had less platelet count.

Conclusion: Near half of patients with B. pertussis and parapertussis have a defect in their vaccination program.

Background and objective: Death of an infant in utero or at birth has always been a devastating experience for the mother and of concern in clinical practice. The aim of this study was to determine the prevalence, probable risk factors and association of stillbirth with different maternal variables in Erbil Maternity Teaching Hospital.

Methods: A cross-sectional design was used to determine the prevalence of stillbirth and a case control design was used to determine the probable risk factors and demographic characteristics of women with stillbirth in Maternity Teaching Hospital in Erbil city, Kurdistan region, Iraq, from April 1^st, to December 31^st, 2011.Three hundred seventy nine women having stillbirth were regarded as cases while 758 women delivering alive newborns were regarded as control group.

Results: The prevalence of stillbirth during the period of the study was 20.4 per1000 total births. Macerated stillbirth was about four times higher than the fresh stillbirth. There were statistically significant differences between the cases and controls in relation to: maternal age (≥ 35 years), level of education, history of antenatal care visits, parity, medical diseases of the mother, congenital anomalies of the newborn, and history of previous stillbirth. In 65.4% of cases the probable cause of death was unexplained.  

Conclusion: The prevalence of stillbirth in the Maternity Teaching Hospital in Erbil is high in comparison to the rate in other countries. This could be due to high level of deliveries per day and lack of good follow up of patients during labour.

Background and objective: A dramatic rise in caesarean deliveries has been occurring over the past three decades. The old myth of “once a caesarean always a caesarean” is no longer acceptable as this increases maternal morbidity. The aim of this study was to evaluate the safety and success of vaginal birth after caesarean section performed before less than two years.  

Methods: A cross-sectional study was conducted in the Maternity Teaching Hospital in Erbil, Iraq from May to October 2012. Ninety two patients meeting the inclusion criteria were included in this study and followed up during their labour. Patients monitored for vaginal bleeding, scar tenderness and tachycardia.      

Results: Of 92 patients with single lower segment caesarean section that underwent trial of labour; 52 (56.5%) patients had successful trial of labour and 40 (43.5%) had a repeated caesarean section. Factors found to be significantly affecting trial of labour were parity (P = 0.01), inter-delivery interval (P <0.001) and cervical dilatation (P = 0.015).   

Conclusion: Vaginal birth after caesarean section is a reasonable choice for women with single lower segment caesarean section with good monitoring of mother and baby during labour. Short inter-delivery period does not preclude vaginal delivery in a woman with single lower segment caesarean section providing that there is no contraindication for vaginal delivery.

Background and objective: Evidence from research is underutilized in policy and practice in the majority of developing countries including Iraq. This aim of this study was to assess the role of research in health policy making in Iraqi Kurdistan context and identify the main barriers and facilitators for enhancing such role. 

Methods: This cross-sectional survey was carried out between November 2013 and March 2014 in the three governorates of the Iraqi Kurdistan Region, Erbil, Duhok and Sulaimaniyah. The study participants included 10 key health informants and three health advisors. Two types of combined questionnaires for health policy makers and health advisors were used for data collection.

Results: Conferences and seminars were the main sources of scientific evidences identified by health policymakers (80%), followed by consultants (70%). Different jargons/discourse was the main obstacle in consulting researchers (90%), followed by lack of tradition in collaborating (70%). Collection of specialists/advisors, followed by professional associations, scientific committees and international organizations/UN agencies were the main groups identified by health advisors to build bridges between the scientific community and policymakers.

Conclusion: Policymakers very rarely consult researchers directly in their decision making. There is poor networking among researchers, policy-makers, practitioners and representatives from civil society which has its negative impact on evidence-based policymaking. There is obviously a lack of any sort of program of funded research that can inform policymaking.

Background and objective: Community medicine is an important discipline for medical students who are going to be future doctors and deal with different health problems. Community Medicine is taught in 3^rd, 4^th and 6^th year of study at Hawler College of Medicine. The aim of the study was to explore students' perception about this subject because it plays an important role in determining educational outcome.

Methods: This study was carried out in Hawler College of Medicine, Erbil city, Iraqi Kurdistan Region in the academic year 2013-2014. It was based on a self-administered questionnaire survey of 4^th year students. The questionnaire consisted of closed and open ended questions related to the attitude of students toward community medicine course, views on the positive and negative aspects and recommendations to improve the course. The quantitative data were analysed through using the statistical package for the social sciences (version 19), while qualitative data analysis comprised thematic analysis of open-ended questions using common coding techniques.

Results: The result of this study suggested that high percentage of the students had positive attitude toward the course. Sixty-six respondents (55.4%) mentioned that there are positive aspects in the course like research project (33.3.1%), having respectful and friendly teachers (31.8%) and participation of students in discussions in the classroom. Sixty-six respondents (55.4%) mentioned that there are negative aspects in the course like short duration of the course (27.2%) and some topics were repeated from other years. Fifty-seven respondents (47.8 %) have recommended a number of priorities for improving the quality of the course like: increasing practical sessions with more student participation (36.8%); decreasing theoretical lectures (22.8%) and the time for the research should be isolated without lectures (19.2%).

Conclusion: Community medicine course is well perceived by the students with some negative aspects. Some recommendations have been made for improving the quality of the course.

Background and objective: Immunohistochemistry is the application of immunologic principles and techniques to demonstrate molecules in cells and tissues. Gene p53 is a tumor-suppressor gene. The product of this gene is a nuclear protein thought to be involved in the control of the cell cycle, apoptosis, and the maintenance of genomic stability. Gene p53 is the most frequently mutated tumor suppressor gene found in human cancer. The aim of this study was to investigate p53 protein over expression in skin cancer and compare it with benign skin lesion.

Methods: A retrospective study was conducted on paraffin block from skin biopsy of 36 patients with various skin lesions; eight benign cases and 28 malignant cases. The sample of patients was collected from the Pathology Laboratory in Rizgary Teaching Hospital in Erbil, Kurdistan region, Iraq from December 2011 to December 2012. The age of the patients ranged from 34 to 80 years. The p53 protein over expression was investigated by immunohistochemical staining. Sample sections were stained and scored.

Results: Nineteen out of 28 (76.8%) skin cancer showed over expression of p53 gene compared with benign skin lesion and there was a statistically significant difference. There was statistical significant difference in relation to the age group of patients with various skin cancers which was higher in patient above 40 years.

Conclusion: Increased expression of p53 a nuclear protein can be detected in human skin cancer compared with benign skin lesion and it may play an important role in pathogenesis of many types of skin cancers.

Background and objective: A thin central corneal thickness has been reported to be a risk factor for developing primary open-angle glaucoma. This has led to a hypothesis that thinning of the cornea may be an indication of generalized weakness of the ocular integument. This study was conducted to explore the relationship between central corneal thickness and axial length in a sample of Erbil population.  

Methods: This is an observational cross sectional prospective study that was conducted from October 2012 to March 2013 and included 260 eyes of 130 patients. The mean age (± SD) was 37.8 ± 17.7 years for males and 35.4 ± 15.5 years for females. Axial length was measured with A-scan ultrasound biometry and central corneal thickness with ultrasonic Pachymeter.

Results: The mean central corneal thickness (± SD) was 542.8 ± 36 µm in male eyes and 530.1 ± 32.5 µm in female eyes. The mean axial length (± SD) was 23.38 ± 1.1 mm in male eyes, 23.15 ± 1.2 mm in female eyes. Central corneal thickness was not correlated with axial length (Pearson correlation coefficient r = 0.037, P = 0.558).

Conclusion: Central corneal thickness and axial length of the eye are two independent measurements. Thin corneas are not related to longer eye. 

Background and objective: Malt beverage without alcohol (Barbican) is an energy beverage which is regularly consumed by Muslim countries and substantial quantities are exported to the Gulf States and Middle East countries. Barbican is used widely by people whom alcohol is forbidden either on medical grounds or on religious aspects. The aim of this study was to assess the effect of short-term drinking of Barbican on urinary excretion of calcium and uric acid in normal young males in Erbil city.

Methods: Thirty healthy male volunteer subjects of 21-23 years age consumed 330 ml of Barbican® beverage per day for two successive days after cross design. The urinary calcium and urinary uric acid were evaluated before and after consumption. 

Results: There was no statistically significant increase in urinary uric acid before and after consumption of Barbican beverage (P = 0.071). Urinary calcium significantly decreased after consumption of Barbican drink (P = 0.037).

Conclusion: Although many extrinsic and intrinsic factors influence formation of kidney stones and bone resorption, this study suggests that drinking of Barbican beverage may be helpful to prevent bone resorption and also to reduce risk of stone formation.  

Background and objective: Evidence-based medicine, by guiding medical care towards meaningful outcomes to patients, has a significant worldwide impact on medical care and education. It is important that medical students, whom are the future physicians, keep themselves updated with recent advancement in medical knowledge and health care. The aim of this cross-sectional study was to determine the attitude, knowledge and barriers among students towards evidence-based medicine and making them familiar with the concept and advantage of evidence based medicine.

Methods: A cross-sectional study was conducted on 163 sixth year students of the College of Medicine at Hawler Medical University during the period from October 2012 to May 2013. The response rate was 86.5%. Knowledge towards evidence-based medicine, accessing and interpreting evidence and perceived barriers to practice evidence-based medicine among participants were the main outcome measures. 

Results: Of 141 of participants that filled the questionnaire, only 69.5% had heard about evidence-based medicine. Around 82% stated that they had known evidence-based medicine and only 23.5% had known steps of evidence-based medicine. Around 65% of respondents welcomed the promotion of evidence-based medicine and 74.4% agreed with that finding from the current study in which it would be helpful in daily management of patients. Furthermore, 31.6% of students reported that standard textbook as a frequent source used for medical knowledge. Around 91% of students did not know the strongest evidence in the hierarchy of evidence and only small proportion of students reported that they understand the common epidemiological concepts that are used in evidence-based medicine.  

Conclusion: Evidence-based medicine is relatively a new concept among students at the College of Medicine in Erbil. Although the students appeared interested in learning and implementing evidence-based medicine in clinical practice, they need more guidance and training to ensure the correct use of evidence-based medicine ideals.

Background and objective: Maternal deaths are still leading problems in many developing countries, including Iraq. Iraq is, in fact, far away to reach the Millennium Development Goal declared to reduce the maternal mortality ratio by three quarters between 1990 and 2015. The aim of this study was to highlight the main causes of avoidable deaths that lead to maternal mortality among those admitted to Maternity Teaching Hospital in Erbil.

Methods: This survey was carried out in the Maternity Teaching Hospital in Erbil city, Kurdistan region, Iraq. Variables included in this study were those related to patient’s age, number of parity and mode of delivery of the last baby. Data were collected from patient’s records. In addition, some clinical data were included related to causes leading to death and underlying condition of death. 

Results: Of the total 75000 live birth recorded in the hospital during the study period (2011-2013), 33 maternal deaths were recorded which gives an overall maternal mortality ratio of 44 per 100,000 live births. Pre-eclampsia and eclampsia were among the top causes of maternal deaths in this study (42.4%) followed by obstetrical bleeding and rapture uterus (30.3%).  

Conclusion: Maternal mortality rate in Maternity Teaching Hospital was 44/100,000 total live births. The main cause of the maternal deaths was pre-eclampsia and its complications. Most of those died were residents of rural areas and were illiterate women. 

Background and objective: Estimation of C-reactive protein is a simple method and could be helpful in detecting cases at risk for pre-term delivery. In this study we examined the association of maternal C-reactive protein in second trimester with risk of occurrence of preterm delivery later on.

Methods: A prospective case-cohort study was conducted between June 2011 and July 2012 at Maternity Teaching Hospital Iraq- Erbil. The sample size was 205 women at gestational age of 20⁺⁰ weeks to 26⁺⁶ weeks and after exclusion of all risk factors for preterm delivery. High-sensitivity C-reactive protein assays were performed on serum samples.  

Results: Median concentration of C-reactive protein was 4.7 mg/liter. No significant association was found between high level of C-reactive protein and occurrence of preterm delivery (P = 0.78).

Conclusion: Measurement of C-reactive protein in second trimester cannot be used as an indicator for pre-term delivery.

Background and objective: An expectation of beautiful smiles at the end of orthodontic treatment is a primary concern to each patient, but is also equally concerned with appearance while undergoing treatment. The development of appliances that combine both acceptable aesthetics for the patient and adequate technical performance for the clinician is the ultimate goal. The aim of this study was to compare three different aesthetic orthodontic techniques with different biomechanics in order to quantify the efficiency of these techniques in alignment of displaced upper right central incisor and investigating the effects of these variables on alignment considering its tipping and rotation.

Methods: The sample consisted of three groups with each group including 15 samples; (1) conventional buccal technique group, (2) lingual technique group and (3) Inman Aligner group, all on a typodont simulation system (dentsply). Preoperative and postoperative digital images were taken and analyzed using Autodesk AutoCAD software. 

Results: The conventional buccal technique gave rise to the highest mean of tooth tipping and rotation followed by the lingual technique. The Inman Aligner produced the least level of tooth tipping and rotation.

Conclusion: The best method of alignment is the conventional buccal technique followed by the lingual technique. The least favourable one is the Inman Aligner.